West Baltimore Health Enterprise Zone A Project of the West - - PowerPoint PPT Presentation

West Baltimore Health Enterprise Zone

A Project of the West Baltimore Primary Care Access Collaborative

April 2, 2015

Community Health Resources Commission

West Baltimore CARE: Year 3 Focus

• Leverage and build upon the collaborative partnerships,

infrastructure, performance data and lessons learned from Years 1 and 2 to: 1) Strengthen and ensure alignment of West Baltimore CARE with the legislative intent of the HEZ Program: Reduce health disparities among racial and ethnic minority populations and among geographic areas; Improve health care access and health outcomes in underserved communities; and, Reduce health care costs and hospital admissions and re- admissions. 2) Ensure the sustainability of the West Baltimore CARE post 2016.

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West Baltimore CARE Overview

• HEZ Geographic and Target Population:

86,000 West Baltimore residents within the 21216, 21217, 21223, and 21220 zip codes

• Core Disease and Target Conditions:

Cardiovascular disease (CVD) and CVD risk factors (i.e., diabetes and hypertension)

• Overarching Strategies: Care

Coordination and Community-Based Risk Factor Reduction

• Year 3 Budget Request: $1,188,522

‒ Year 3: $1,041,887 ‒ Year 2 Funds not expended (carried over into Year 3): $146,635 3

Figure 1. WB HEZ Geographic Area

WEST BALTIMORE CARE YEARS 1-2: ACCOMPLISHMENTS, CHALLENGES AND LESSONS LEARNED

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Collective Impact Accomplishments: Partners Across the Zone Working Together

Legislatively Specified Outcomes

Systems of Learning

• Monthly Care

Coordination Meetings among Clinical Partners

• Data Sharing

Infrastructure for Collection of Clinical Measures

• Student Interns

Collaboration

• Care Coordination
• CHW Training
• Nutrition/Cooking

Classes Taught by Community Partners

• Disease Management

Classes Taught by Community Partners Increased CVD Screening

• PCMHs
• Clinical Measure

Reporting (NQF or UDS)

• Increased Number of

Providers

• Health Fairs

Improved Care Coordination

• Piloting CRISP use at

Bon Secours

• Continuing education

for CHWs Increased Community Based Risk Factor Reduction

• Fitness Classes
• Community

Partnership grants

• Nutrition/Cooking

Classes

• Disease

Management Classes

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Health Promotion Courses

• Conducted 14 disease self-management classes with a total of 84

participants

• Stanford Chronic Disease Self Management Program
• Conducted 24 nutrition/cooking classes with 223 participants

Community Health Outreach

• Community Heath Workers engaged 4,612 community members

and patients

• Health Screenings, Education, Emergency Department, Home

and Clinic Visits

Incentivizing Risk Reduction

• Leveraged 4 grants to community partners to reach 4,300

community members

• Enrolled 859 participants in our ‘Passport To Health’ Program
• Points are given for healthy behaviors

*Note: All numbers are through December 2014.

Strategy Outcomes 6

Goal: Improved Risk Factor Prevalence Strategies and Outcomes*

Tax Credits and Loan Repayment

• 5 Qualifying providers received $26,205 in State tax credits

Health Career Scholarships

• Awarded 29 scholarships averaging $2,500
• Predominantly for entry level health professional programs

(8wk-24month in length)

• Anticipate 30 FTEs will be filled by scholars by April 2016

PCMH

• Conducted a Zone wide PCMH training by a contractor for Clinical

Partners

• Purchased online self-study curriculum for use by practices

*Note: All numbers are through December 2014.

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Goal: Expanded Primary Care Workforce*

Strategy Outcomes

Community Health Outreach Team

• Hired 5 FTE paid CHWs
• Selected 6.5 FTE Intern CHWs

Training

• Trained 89 community members through free

Community Health Worker trainings

*Note: All numbers are through December 2014.

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Goal: Increased Community Health Workforce*

Strategy Outcomes

Fitness Classes

• Hosted 11 Free Weekly Fitness Classes with a total of 678

participants

• Yoga, Line Dancing, Zumba, Kick-boxing

Nutrition Support

• Promoted and modified DinnerTime for our population
• Web based meal planning platform to aid implementation of

medical dietary instruction

• Modified for smart phone use and health literacy level
• Advertised a twice a month Produce Market (collaboration with

Bon Secours)

Engagement

• Awarded $70,000 to seven community partners for CVD

programming

• Held 7 Capacity Building Workshops with a total of 73

participants

*Note: All numbers are through December 2014.

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Goal: Increased Community Resources for Health*

Strategy Outcomes

Care Coordination

• Community, Out-Patient and ED/Hospital Based
• 352 Community members partnered with Community

Health Workers 10

Goal: Reduced Preventable Emergency Department Visits and Hospitalizations*

Strategy Outcomes

*Note: All numbers are through December 2014.

Year 1 and 2 Challenges and Lessons Learned

Challenge Lesson Learned

1) Data Integrity Due to Multiple Systems used across Partner Organizations and Program Activities Consolidating data collection mechanisms and responsibilities as much as possible limits errors. 2) Staff Turnover Choosing individuals who can be flexible in order to work in a pilot program environment where change is constant. 3) Introduction of New Software Creating a realistic plan for implementation and training improves adoption and creates clear expectations across stakeholders. 4) Ability to identify High Utilizers The use of a single definition across Clinical Partners and ability to track high utilizers in our database increases our ability to impact legislatively defined

• utcomes.

5) Alignment of program strategies and budget with legislative intent Increasing our use of metrics allows us to quickly determine if our strategies/activities work toward the legislative intent of the program.

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West Baltimore Care Year 3: Path Forward

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• Continue to target 86,000 West Baltimore residents
• 1,575 high utilizers who are subset of the 86,000 residents
• Strengthen the connection between hard to reach, high cost

populations and primary care providers.

• Address social determinants of health: utilities, housing, food access

13 Program Components Added Clinical Expertise Resource for CHWs Two-tiered Care Coordination to Meet High Utilizer Needs Expanded Patient Tracking Software 30-Day Care Plans and Behavior-Based Goals Streamlined Referrals Proactive, Structured Patient Contacts Improved Caseload Management

Care Coordination Priorities and Program Redesign Components

Year 3 Care Coordination Redesign

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• By March 31, 2016, successfully connect 1,125 high utilizers to a

Community Health Worker and provide prolonged support to 450 high utilizers.

• By March 31, 2016, Community Health Workers will provide 4,725

encounters via home visits, phone, health screenings and clinic visits.

• By March 31, 2016, successfully connect 100 high utilizers to a

primary care provider (PCP).

15 Strategies Care Coordination: Re-designed program Technology: Patient Tracking Platform and Care at Hand Referrals from WBPCAC Clinical Partner Hospitals: St. Agnes, Bon Secours, UM Midtown, UM Medical Center, Sinai of Baltimore

High Impact Objectives and Strategies

Process Measure Annual Goal*

1) High Utilizers to CHWs (Tier 1) 1,125 2) High Utilizers to CHWs who need prolonged support (Tier 2) 450 3) Home visits 1,125 4) Phone contact 3,150 5) Clinic Visits 150 6) Health Screenings (done at each encounter) 4,725 7) Number of medically homeless participants referred to a PCP 100 8) By March 31, 2016, increase by 3% the percentage of WBPCAC hypertensive adult patients with blood pressures lower than 140/90mmHg. 224** 9) By March 31, 2016, increase by 3% the percentage of WBPCAC diabetic adult patients with LDL-C <100 mg/dL. 272*** 10) By March 31, 2016, increase by 3% the percentage of WBPCAC diabetic adult patients with HbA1c under control. 260**** 16

*Note: Goals are calculated with planned start of program to start in June 2015. ** based off of a targeted population of 7,481 (denominator for quality measure ) in calendar year 2013; ***based off of targeted population of 9,075 in calendar year 2013****based off of targeted population of 8,650 (denominator for quality measure) in calendar year 2013

High Impact Objectives Process Measures and Health Outcome Objectives

Budget Priorities and Key Interventions

• Overarching Strategy #1 – Care Coordination

($453,629- 38% of funding total)

‒ Technology: $78,800 ‒ Evaluation: $23,870 ‒ Implantation Support: $350,959 ‒ $20,000 (Pilot Implementation, Training, Continuing Education) + ‒ $330,959 (6.5 FTE Assignment)

• Overarching Strategy #2 – Community-Based

Risk Factor Reduction ($460,500 39% of funding total)

‒ Strategy 2.1 - Increased Identification and Screening of Individuals with CVD or at risk for CVD: $118,640

• $58,000 (Provider quality incentives) +

$23,870 (clinical measure evaluation) +$36,770 (biometric assessment vendor) ‒ Strategy 2.2 - Recruitment of Primary Care Professionals and Paraprofessionals: $20,000

• $20,000 State Tax Incentives

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38% 39% 23%

Strategies and Resource Allocation

Care Coordination Community Based Risk Factor Reduction Meeting and Other Expenses (Indirect, Fringe, etc.)

Budget Priorities and Key Interventions

• Overarching Strategy #2 – Community-Based Risk Factor Reduction

($456,630- 39% of funding total)

‒ Strategy 2.3 - Scholarships to Expand Care Teams with Community Members: $117,878

• $97,878 (scholarships) + $20,000 (4 student stipends)

‒ Strategy 2.4 - Patient Education: $25,000

• $25,000 (Nutrition, cooking, disease management and capacity building

classes) ‒ Strategy 2.5 - Physical Activity: $22,000

• $22,000 (Fitness classes and incentives)

‒ Strategy 2.6 - Community Partnership Grants: $50,000

• $50,000 (Community Partnership Grants)

‒ Implementation Support 2.5 FTE: $106,982

• $10,000 (Training, Facilitation)
• $96,982 (FTE assignment)

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Partnerships and Sustainability

• During the past two program years, we leveraged partnerships with

25 organizations across the Zone to provide in-kind and paid activities.

• WB CARE successfully acquired $132,610 in additional grant dollars

to directly support HEZ activities enabling us to provide disease management classes, purchase incentives to promote resident participation in Passport to Health activities, and expand our efforts to aid in meal planning from several granting organizations including PNC Bank, Baltimore City Health Department, and the Family League

• f Baltimore.
• We have the support of multiple WBPCAC members with fundraising

resources committed to expanding these funding relationships in addition to other funding resources such as insurance carriers.

• We plan to evaluate our care coordination model to see if there is a

business case for additional funding (i.e., capitated payments) by public or private entities.

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Questions